Preventive Surgery Options
The higher a woman's risk of breast cancer, the more likely she is to benefit from preventive surgery. If a woman's risk is estimated to be 80%, it could be lowered to about 8% by preventive breast removal. If her risk of ovarian cancer is estimated to be 40%, it could be lowered to about 8% by preventive removal of her ovaries. And removal of ovaries (without breast removal) in a pre-menopausal woman can reduce her risk of breast cancer by 50%, or half (80% drops down to 40%).
After you are done having children, you may choose to have your ovaries and fallopian tubes removed and then be closely monitored by your doctor. You may postpone or decide against removal of your breasts.
The surgical options — removal of breasts and ovaries — are called “prophylactic,” which means “protective.” If you take these steps, you are doing something that will significantly reduce your risk for cancer in the future (although there is no guarantee). These options are permanent and irreversible.
Prophylactic mastectomy and removal of the ovaries
Preventive breast removal surgery may be able to reduce a woman's risk of developing breast cancer by approximately 90%. The procedure removes nearly all of the breast tissue, so there are very few breast cells left behind that could develop into a cancer. Preventive removal of the ovaries (oophorectomy) also removes the fallopian tubes to make sure that all ovary-like tissue has been completely removed. This procedure can reduce the risk of ovarian cancer by about 80%.
For cancers linked to abnormal breast cancer genes, the type of abnormal breast cancer gene a woman has seems to influence how much risk reduction she gets from preventive ovary removal. A 2008 study by researchers at Memorial Sloan-Kettering Cancer Center found that in women who had an abnormal BRCA1 gene, removing the ovaries was more beneficial for lowering ovarian cancer risk than lowering breast cancer risk. In women who had an abnormal BRCA2 gene, removing the ovaries was more beneficial for lowering breast cancer risk than ovarian cancer risk.
You might be wondering how removal of the ovaries could lower the risk of breast cancer. The main reason is that it lowers the amount of estrogen available to stimulate the start or development of a hormone-receptor-positive breast cancer.
Since removal of the breasts protects against breast cancer and removal of the ovaries protects against both breast and ovarian cancer, you might wonder: Would a combination of surgeries give a pre-menopausal woman even greater protection than one procedure alone? When it comes to just reducing the risk of breast cancer, having both kinds of surgeries would be considered very aggressive. Once both breasts are removed and the risk of breast cancer goes from 80% down to 8%, is it worth also removing the ovaries to bring that 8% down further? Your answer to that question depends on your own unique situation. Some women might say: “YES! I'm going to do everything possible to reduce my risk.” Someone else might say, “I'll only take out my ovaries if I'm at increased risk of ovarian cancer. And I'll do that surgery when I'm close to menopause (when their removal has less of an impact on my quality of life). Until then I'll be sure to stick to close follow-up.”
If you have an abnormal BRCA1 or BRCA2 gene and want to be as aggressive as possible about your care, talk to your doctor about the role of preventive surgeries to lower your risk of developing breast and ovarian cancer.
Still, it's important to keep in mind that the surgery is not “guaranteed” — it's only about 90% effective. You could still develop breast cancer despite the procedure, because not all cells that could potentially become cancerous can be removed. (The breast is surrounded by tissue — skin in the front, muscle in the back. It's impossible to remove every single last breast cell off of the skin and muscle.) Instead of having preventive breast removal, you might choose to reduce your risk of breast cancer with anti-estrogen hormonal therapy or by having your ovaries removed if you're pre-menopausal. No matter what your strategy is to reduce your risk, close follow-up remains critically important.
Combining protective measures
Some of these risk reduction options can be combined and some can be used in sequence. For example, you might choose to have your ovaries and fallopian tubes removed now and then be closely monitored by your doctor. You might postpone or decide against removal of your breasts and opt for just close follow-up. Over time, you might also consider taking tamoxifen to reduce your risk. Or you might participate in a clinical trial that offers a newer form of treatment to reduce risk.
The side effects of these procedures need to be weighed against their protective benefits. Besides involving surgical risks, removing your breasts may cause a lowered self-image and reduced sensitivity and sexual response, which may affect your quality of life. Removing your ovaries can cause problems with self-image and sexual function and will bring on menopause, which may affect your bone health.
These decisions require a great deal of thought, patience, and discussion with your doctors, genetic counselors, and family — plus a tremendous amount of courage. Take as much time as you need to consider these options and make decisions that you're comfortable with. There is no rush to decide.
